Can You Vape to Death?

I never thought I’d see the day, but vaping—the bejewelled fedora of nicotine delivery methods—is starting to seem a lot less ridiculous. Or, at least, somewhat less ridiculous. Juuling teens are still reliably funny. But at the same time, there are real, credentialed doctors out there making a case for vaping as a viable alternative to conventional smoking. One doctor, speaking to the New Yorker, claimed that if 10 per cent of the cigarette smoking population switched over to e-cigs, 6.6 million lives would be saved. Of course, we’re still unclear on what the long-term risks might be—some studies have suggested that e-cig vapour can be carcinogenic, and contain arsenic and lead. So if we’re all going to switch over to vaping, it might be useful at least to know, in the short-term, if it could possibly kill you.

And so, for this week’s Giz Asks, we reached out to a number of nicotine scholars to figure out whether it’s possible to OD from vaping. The consensus, for the most part, is: no, unless you’re a toddler confusing nicotine liquid for candy. But that doesn’t mean overdosing is physically impossible, or that all our experts are in favour of e-cigs.

Dorie Apollonio

Associate Professor, Clinical Pharmacy, University of California San Francisco, focusing on tobacco control and policy making

Well, the word overdose is a little odd here, because overdose just means an excessive or dangerous dose of a drug, and since nicotine has no therapeutic use, and it’s addictive, and it probably has some toxic effects, anything is an overdose, technically speaking.

But to the question of what’s a level of toxicity that’s dangerous—that depends on the person. If you’re an adult who's built up a tolerance of nicotine, then you can continually take low doses without any real significant harm, assuming that you’re in the right population group. (We know that it causes birth defects, so pregnant woman shouldn’t be exposed to nicotine, and that adolescents can get brain damage and cognitive disorders as well as addiction from exposure to nicotine.)

You hear people saying that nicotine replacement therapy—like a patch or a gum—is safe, but that’s because it’s only given to smokers who’ve already built up a tolerance. Whatever they’re taking from nicotine replacement therapy is a lower dose, so they’re better off. And the reason that people are a little bit cautious about making the same claim about e-cigarettes is, it’s not clear that people are getting a lower dose of nicotine [from them]—though they’re probably getting less toxicity from the aerosol, because you’re not burning it the way that you are with a conventional cigarette or a combustible cigarette.

But can you die from vaping? The answer is: yes, technically, but it’s kind of hard, for the same reason that it’s difficult to die from an overdose of combustible cigarettes—and that’s because you’d get sick. And one of the symptoms of that is nausea and vomiting, which is immediately knocking stuff out of your bloodstream and your stomach.

That said, it’s possible, especially because with a lot of nicotine solutions it’s unclear how much nicotine is in them, and they move into your system pretty rapidly. But you’d really have to work at it to kill yourself.

It is much easier for children, because children can drink nicotine solution—especially flavoured nicotine solution, that smells to them like candy. There aren’t necessarily childproof caps on nicotine solution—that is not a US federal law—so poison control gets a lot of calls about kids who smell a sweet-smelling nicotine solution, drink it and get poisoned. I think only a couple of them have led to death, but certainly there have been permanent health effects from those overdoses—they’re highly toxic for those populations.

My personal position as a tobacco control researcher is if you really wanna stop smoking we have all kinds of great drugs that help you with that like nicotine replacement therapy and bupropion, and so e-cigarettes are kind of a solution in search of a problem.

“Since nicotine has no therapeutic use, and it’s addictive, and it probably has some toxic effects, anything is an overdose, technically speaking.”

Riccardo Polosa

Director, Institute for Internal Medicine and Clinical Immunology, University of Catania and Head of the Centre for Tobacco Research

Nicotine overdose (i.e. nicotine poisoning) is unlikely to be a real concern for the average e-cigarette users. In general, smokers (and by analogy vapers) titrate their nicotine needs based on the feedback they receive from their body. Sensations of vertigo or nausea are signs of excessive nicotine intake. Feelings of tiredness, daze and confusion are signs of low levels of nicotine instead. As a result, smokers self-regulate nicotine intake to meet their psycho-physical needs.

With the exception of those suffering from serious psychiatric conditions, it is rare to experience symptoms of overdose—e.g., progressive agitation, nausea, vomiting, tachypnea (accelerated breathing) tremors and/or loss of consciousness. Nonetheless, it is not uncommon for occasional smokers initially trialling high nicotinised e-cigarettes to experience symptoms of nicotine intoxication. To avoid this, it is best to experiment with low/medium nicotine concentrations (depending on the level of nicotine present in their conventional cigarette brand) at first.

Also, it is unlikely that overall daily nicotine uptake from e-cigarette use will be higher than cigarette smoking. User’s puffing behaviour and experience with the product together with the level of nicotine concentration in the e-liquid being consumed and the product design play an important role in dictating nicotine absorption.

It is also highly unlikely that e-cigarettes promote higher daily consumption of nicotine than tobacco cigarettes. There is no evidence of this ever occurring, no evidence of nicotine overdosing has been reported, even under conditions of compensatory puffing. There is evidence that levels of plasma nicotine and cotinine (a stable metabolite of nicotine) in vapers who have switched to e-cigarettes are comparable to that of cigarette smokers.

Quite frankly I would be more concerned with daily consumption of large volume of e-liquids because of the potential of increasing the exposure to unknown toxicants.

“I would be more concerned with daily consumption of large volume of e-liquids because of the potential of increasing the exposure to unknown toxicants.”

Stanton A. Glantz

Truth Initiative Distinguished Professor of Tobacco Control, Center for Tobacco Control and Education, University of California, San Francisco

Yes. Unlike conventional cigarettes, whose physics limit how fast you can puff them, there is no intrinsic limit to how quickly or how many puffs you can take at one time from an e-cigarette. In addition, the amount of nicotine in an e-cigarette can be much larger than a pack of conventional cigarettes. While rare, I have heard of people who puffed e-cigarettes so many times in a row that they got sick with nicotine poisoning.

A bigger problem is likely to come from exposure to the concentrated nicotine liquid used to fill e-cigarettes, which can be absorbed through the skin or drank (particularly a problem with infants and children, who think it is candy). As e-cigarettes have become more popular, calls to poison control centers for nicotine poisoning have skyrocketed, with over half involving kids under 5. There has been one confirmed death for e-cigarette-related nicotine poisoning, an infant in upstate New York, who drank the e-liquid. That’s one death too much.

Jamie Brown

Deputy Director, Tobacco and Alcohol Research Group, University College London

It would be nearly impossible to overdose by vaping. The time it takes for nicotine to reach lethal concentrations by inhalation would mean you became violently sick and too unwell to continue vaping (and you would get strong bodily feedback that you should stop considerably before that unless it was intentional). In reality, people with a small amount of experience with things that deliver nicotine (like cigarettes, e-cigs, NRT) become exceptionally good at titrating their consumption to suit their needs. If you swallowed enough e-liquid deliberately or by accident, then it would be possible. Accidental poisoning among children is a risk which means ideally e-liquid bottles should be tamper-proof and kept out of reach of children like medicines.

Lion Shahab

Associate Professor, Behavioural Science and Health, University College London

It is very difficult indeed to overdose on vaping when using e-cigarettes as directed. This is because nicotine is eliminated relatively quickly from the body and bioavailability—that is, how much nicotine is transferred from the carrier to the body—is relatively low, at around 20% orally.

If we assume that the lethal dose at which 50 per cent of users would die (LD50) is around 0.5-1g of ingested nicotine—around 6.5-13 mg/kg—this means that even at higher concentration levels (20 mg/ml) the average human would need to consume 25-50ml of e-liquid within a very short amount of time.

To put this in context, average daily consumption of e-liquid is less than 5mL a day (irrespective of concentration). Someone would need to vape constantly to get to this level of consumption, and because nicotine is aversive, signs of nicotine poisoning would include vomiting so it is unlikely anyone would ever manage to vape this much e-liquid in a short amount of time.

A helpful comparison is to look at coffee. An average human can die from drinking 70-100 cups of coffee, but cases of caffeine overdosing are also very rare, because, as with nicotine, it would result in vomiting before enough coffee could be consumed. Therefore the only way that nicotine can readily result in overdosing is to consume it orally by drinking e-liquid.

In terms of long-term health effects of vaping, these are currently difficult to estimate because of the long time it takes for health problems to manifest: we simply do not have the data yet. But looking at early signs and biomarkers, which we know are related to later health outcomes (such as cancer), the data seem to suggest that e-cigarettes (compared with smoking cigarettes) are several orders of magnitude safer—though obviously not risk-free compared with not using anything.

Jonathan Foulds

Professor, Public Health Sciences & Psychiatry, Penn State University College of Medicine

Someone who uses nicotine products regularly (whether it be cigarettes, e-cigs or smokeless tobacco) is very unlikely to overdose on the nicotine from vaping, just as hearing about someone “overdosing” on nicotine from cigarettes is extremely unusual. Those who do absorb too much nicotine are usually novice nicotine users with minimal tolerance for nicotine. It is not uncommon for a non-smoker to feel nauseous and maybe even vomit the first time they smoke a whole cigarette, and a novice vaper could have a similar experience.

In addition, even a moderately experienced vaper (or cigarette smoker for that matter), could inhale excessive amounts of nicotine if they chose to persist vaping intensively despite the onset of unpleasant side effects. This usually starts with feeling sweaty, palpitations, dizziness etc. and progresses to vomiting. Most people learn very early how to dose themselves to avoid this.

Of course overdosing by drinking e-liquid is a whole different story, and the amount of nicotine in a tank or bottle could kill someone if they consumed it all.

Nicotine poisoning from normal use is very rare, regardless of the product, but we don’t yet know what the long term effects of vaping are.